Now that competition for the next U.S. presidential election cycle has begun heating up, it is common to hear candidates boast that this nation is the greatest on earth. That claim often is perceived as being true in the aggregate, but there also is some value in taking into account certain qualifiers, such as life expectancy trends. The September 2023 issue of the American Journal of Public Health contains several items regarding this particular topic.
One point of view is that the United States suffers from a health disadvantage. The U.S. population experiences poorer health than populations in other countries and the disadvantage has grown over time. A component of this phenomenon is the U.S. life expectancy disadvantage. Survival in the developed world has increased over the past century, but growth in this country’s life expectancy has not kept pace with that of other industrialized countries. Moreover, the gap with other nations widened dramatically after 2010, when life expectancy plateaued here, but continued increasing elsewhere.
A recent demonstration of the U.S. health disadvantage occurred during the COVID-19 pandemic, when the United States experienced more deaths from this disease than any other country and had among the highest per capita death rates. U.S. life expectancy decreased by 2.1 years between 2019 and 2021, the largest decline in a century. Other high-income countries experienced smaller decreases in life expectancy during the pandemic, widening the gap to historic levels. The U.S. life expectancy disadvantage began decades ago, but exactly when remains unclear. Studies typically date the onset to the 1980s or 1990s, raising intriguing research questions about events in history that might explain this timing.
Researchers usually measure the U.S. life expectancy gap in reference to “peer countries,” typically selecting high-income—and largely Western European or Anglo-Saxon—countries as the comparison group. The implicit assumption is that less affluent or developing countries are unlikely to outperform the United States and cannot serve as a benchmark for documenting a U.S. disadvantage. The validity of either assumption—that only high-income countries surpassed the United States and that the phenomenon began in the 1980s to 1990s—is unclear.
A 2013 National Research Council report explored five domains that might explain the U.S. health disadvantage—health systems, individual behaviors, socioeconomic factors, the environment, and policies and social values—and with each domain found distinctive U.S. characteristics that might contribute to poorer health. Potential contributors included not only downstream, proximal factors, such as obesity, substance abuse, and deficiencies in the U.S. health care system, but also upstream, macrostructural factors, such as U.S. policies. For example, countries with better health outcomes typically offer more generous social welfare and income support programs and enforce stronger regulations to protect public health and safety. Going forward, a prudent first step could be to examine policies that have enabled other countries to outperform the United States for decades.